Theory and Bioethics _ a Taxonomy of Theoretical Work in Bioethics (Stanford Encyclopedia of Philosophy)

2/23/2015 Theory and Bioethics > A Taxonomy of Theoretical Work in Bioethics (Stanford Encyclopedia of Philosophy)

data:text/html;charset=utf8,%3Ch2%20style%3D%22margin%3A%200.7em%200px%200.5em%3B%20fontfamily%3A%20'Source%20Sans%20Pro'%3B%2… 1/9

A Taxonomy of Theoretical Work in BioethicsFor those who wish to delve deeper into the subject of theory in bioethics, I offer here a discursivetaxonomy of the various sorts of inquiries that might plausibly be labeled “theoretical” within the bigtent of bioethics. Rather than attempting a serviceable definition of theory—or a list of reliable criteria—up front, we'll review a number of theoretical inquiries in bioethics and list en passant whatevercrucial defining features they might suggest.

1. Rooting out bad theoryThere is a use for theory that even the most antitheoretical commentators have endorsed: viz.,countering all the bad, implicit theory that infects so much public discussion of bioethical matters.Even if we follow Robert Fullinwider's (2007) advice to eschew theory in favor of common morality,actual social practices and institutional norms as our primary sources of practical moral reasoning, wewill surely find, as Fullinwider warns, that those very practices and norms are riddled with “badtheory” or “metaphysical baloney” of all kinds, much of it stemming from provincial social attitudesand uncritical religious beliefs. Since cataloguing the vast expanse of bad metaphysics and moraltheory embedded in past bioethical debates would itself require an entire encyclopedia entry, I willlimit myself here to just a couple of examples, chosen more or less at random.

Costeffectiveness analysis. Although there is no doubt that cost effectiveness analysis (CEA) can bean extremely useful tool or adjunct in setting health care priorities, there is plenty of reason to beskeptical when CEA operates, as it often does in health policy circles, as unquestioned dogmaregarding the sole proper criterion for allocating of health resources. As a direct offshoot of welfareeconomics and ultimately of utilitarian moral theory, CEA is premised on the notion that justice in thedistribution of healthrelated goods is equivalent to the maximization of benefits or, more colloquiallyput, to getting the most bang for the health care buck. While such formulations have the ring ofcommon sense about them, and while economists often write and speak as though there were norational alternatives to CEA (Eddy 1996), philosophers know alltoowell that utilitarian theories ofjustice are highly controversial at best, and fatally flawed at worst. By focusing exclusively on themaximization of benefits, no matter the fairness of their distribution, utilitarian theory ignores otherfactors, such as claims of equity on behalf of worst off groups, that many people regard as highlyrelevant to just outcomes. In this case, the proper response to bad (or at least controversial) theory isnot to banish theory from bioethics, but rather to propose a better theory, one that directly addressesissues of equity or fairness in the distribution of goods. (Brock 2004)

(b) Muddled distinctions. During the emergence of contemporary bioethics, decisions to forego lifesustaining treatments were often framed by doctors, lawyers and the public at large in terms of wellworn distinctions between ordinary vs. extraordinary treatments, actions vs. omissions, and killing vs.letting die. Physicians often justified their actions (e.g., withdrawing a ventilator or feeding tube) onthe ground that a particular treatment constituted an “extraordinary means;” and in response toworries that withholding or withdrawal a tube might kill the patient, they often claimed that they were“merely omitting” to do something, rather than doing something illicit. But as a devastating report,drafted by philosophers, showed in 1983, such distinctions were inherently vague and tended to focus

[13]

http://plato.stanford.edu/entries/theory-bioethics/notes.html#13

user

Sticky Note

Arras, John, "Theory and Bioethics", The Stanford Encyclopedia of Philosophy (Summer 2013 Edition), Edward N. Zalta (ed.), URL = <http://plato.stanford.edu/archives/sum2013/entries/theory-bioethics/>.



on morally irrelevant features of such cases (President's Commission 1983). When a physician pulls afeeding tube, is she “merely omitting” to do something, which would presumably be licit, or is sheactually doing something, i.e., removing the tube, which would presumably be illicit? Apart from thissort of terminal vagueness, philosophers helpfully pointed out that the moral permissibility of suchlife and death decisions should rest, not on such metaphysically dubious and morally irrelevantdistinctions, but rather, inter alia, on the likely impact of a proposed treatment (or treatmentwithdrawal) on the patient's overall wellbeing.

2. Normative theory2.1 Normative Ethical Theory

The most obvious example of theoretical work in bioethics fits under the traditional rubric of“normative ethical theory.” The point of this kind of theoretical work is most often to justify one'sjudgments bearing on the rightness or wrongness of various individual actions or social policies.Should Doctor Dan lie to his patient in order to facilitate her recovery or induce her to accept what heregards as beneficial surgery? Should the various states legally permit physicianassisted suicide?Who should have first priority on scarce vaccines in the face of pandemic influenza?

If we rule out the use of force in imposing answers to such questions, we must engage in the socialpractice of offering, accepting, and criticizing what we take to be good reasons for our judgmentsbearing on actions and social policies. While appeals to common sense and standard practices willsuffice most of the time, we are often driven to higher levels of moral discourse in order to give asatisfactory justification of our judgments in the face of disagreement and controversy. In working outsolutions to the three practical questions posed above, we might begin to wonder about the weight thatshould be given to consequences versus that given to various commonsensical but nonconsequentialist moral obligations, such as truthtelling, respecting human life, or human equality. Indoing so, we are already fully engaged in the project of normative ethical theory building. Typicalexamples of such theory in bioethics include consequentialism in its various incarnations, includingutilitarianism (Singer 1999); contractualism, including Rawlsian theories of justice (Rawls 1971/1999;Kantianstyle deontology (Donagan 1977), and libertarian political thought (Engelhardt 1996).

2.2 Virtue ethics

Apart from setting out the grounds and scope of moral our obligations and of ethically permissibleconduct and policy, normative ethics also deals with questions bearing on what kind of people weshould be. Instead of focusing on the grounds and criteria of right and wrong conduct (i.e., the what ofethics), virtue ethics focuses on the quality of moral agency (or the who of ethics). This variety ofethical theory ponders the nature of the virtues and their manifestation in virtuous moral agents. Inbioethics, virtue ethics has often focused on the virtues of the good physician or nurse, includingconscientiousness, technical skill, empathy, courage, truthfulness, dedication to the patient's good, andjustice (Pellegrino 1993, Drane 1995).

2.3 High moral theory

Normative ethical theories vary considerably in terms of their aspirations towards generalization,universality, abstractness, systematic organization, simplicity, and comprehensiveness (Nussbaum



2000, Flynn 2007). Paradigmatic examples of what we'll call “high moral theory” attempt to embodymost or all of these defining characteristics. Thus classical utilitarianism, Kantian deontology, andRawlsian justice as fairness, for example, all strive for the articulation of a theoretical system basedupon a small number of abstract fundamental principles (e.g., Mill's principle of utility, Kant'scategorical imperative, and Rawls's famous two principles of justice) that they regard as the “keys” tounderstanding the moral or political life. These principles in their pristine incarnations are capable ofbeing articulated in a perfectly general and universal fashion without any reference to or dependencyupon any particular social practices or cultural norms. They apply, so their authors tell us, to allrational agents as such. Beginning from these highly abstract and universally binding moral norms,standard examples of high moral theory ramify into complex systems encompassing basic andderivative moral principles (e.g., respect the autonomy of rational agents), rules based upon suchprinciples (e.g., do not enlist patients in biomedical research without first gaining their informedconsent), and, finally, judgments animated by such principles and rules bearing on particular cases(e.g., the Tuskegee syphilis study was unethical).

Although most philosophers might naturally think of such highly abstract and ambitious constructionsas paradigmatic examples of moral theory, and most likely have precisely such theories in mind whenasked about the relationships between bioethics and ethical theory, they do not exhaust the space ofnormative theorizing either in bioethics or within the moral life more generally.

2.4 Pluralistic theories

In contrast to typical high, vaulting theory supported by a single keystone, more pluralistic ethicaltheories also purport to offer normative bases for moral thought but with more broadbasedfoundations. In addition to the principle of utility or categorical imperative, such theories consist of aset of fairly heterogeneous moral principles or basic capabilities necessary for human flourishingand/or ethical behavior. One classical example of this genre of moral theory can be found in the workof British philosopher W.D. Ross, whose list of socalled prima facie, obligations—fidelity;reparation; gratitude; nonmaleficence; justice; beneficence; and selfimprovement—clearlyanticipated and inspired the dominant “principlist” approach to bioethics championed by Beauchampand Childress. (Ross 1988, Brody 1988, Frankena 1973)

Importantly, these pluralistic theorists generally refrain from endorsing an a priori ranking—or, asRawls puts it, a ‘lexical ordering’—of the various interests, values and principles they articulate.Autonomy, beneficence, and justice, for example, might all figure in our deliberations about aparticular issue, but their respective weight or importance can only be determined in medias res, givenall the particularities of the case at hand. Gauging which values, principles or rules should determinethe result in a particular case is said to require good judgment, practical wisdom, or intuition of somesort.

Another, very different approach to pluralistic normative theory is developed in the related politicaltheories of Martha Nussbaum and A.K. Sen. (Nussbaum 2000, Sen 1999) Instead of plumbing thedepths of our common morality for deontological obligations in the manner of Ross, Beauchamp andChildress, Nussbaum offers us a neoAristotelian theory of the prerequisites of human wellbeing orflourishing. In contrast to others within the big Rawlsian tent who would measure progress onachieving equality by focusing on the resources or primary goods held by individuals, both Nussbaum

[14]




and Sen explicate the “metric of equality” as the measure of what individuals are able “to be and do.”Towards this end, Nussbaum (but not Sen) has developed a list of 10 basic capabilities required for alife that is truly commensurate with human dignity:

1. Being able to live a life of normal length.

2. Having adequate bodily health and shelter.

3. Bodily integrity.

4. Being able to use one's senses, imagination, and thought; to experience pleasure and avoid pain.

5. Emotional expression and development.

6. Practical reason, being able to critically reflect on one's own life, liberty of conscience.

7. Affiliation with others and possessing equal dignity in society.

8. Other species. Being able to live with concern for and in relation to animals, plants, and theworld of nature.

9. Play. Being able to laugh, to play, to enjoy recreational activities.

10. Control over one's environment, both politically and materially.

According to Nussbaum, all of these basic capabilities are crucial prerequisites of human flourishing,and none should be traded away for more of the others. This kind of pluralistic moral/political theoryhas gained considerable traction in the areas of public health and global bioethics (Powers and Faden2006).

These pluralistic accounts of normative theory frequently encountered in bioethics usually feature theselective appropriation of various themes or theory fragments borrowed from elements featured instandard highlevel theories (Baker and McCullough 2007). The socalled principle of autonomyprovides an interesting case in point. As articulated in some of the foundational documents of thecontemporary bioethics movement, such as the seminal Belmont Report on the ethics of research withhuman subjects, and Beauchamp and Childress'sPrinciples of Biomedical Ethics, the principle ofautonomy was put to work in the highly successful battle against a wellentrenched medicalpaternalism that arrogated decision making prerogatives to physicians and biomedical researchers.(President's Commission 1978, Beauchamp and Childress 1977). The interesting thing about thisprinciple of autonomy or “respect for persons” is that it seems to have been cobbled together from avariety of theoretical sources (Beauchamp 2007). Clearly, the principle has unmistakable Kantianovertones. Respect for the moral autonomy of persons is an absolutely fundamental element ofKantian moral theory. But the contemporary understanding of autonomy within the field of bioethicshas been distinctly unKantian in its jettisoning of Kant's metaphysics of action and his key distinctionbetween autonomy, defined as allegiance to universal and rational moral law, and heteronomy,defined as the determination of action by “mere” individually defined interests. So in spite of thedistinct Kantian flavor of a term like “respect for persons” in the bioethics literature, usually all thatremains of the Kantian understanding of autonomy in this field is a broadly defined notion of selfruleor individual choice that is equally compatible with a Millian notion of liberty and with what Kantwould have deemed heteronomous springs of action.



Thus, in addition to this Kantian strain in the contemporary bioethical understanding of autonomy,there are distinctly utilitarian or consequentialist motifs borrowed from such works as J.S. Mill's OnLiberty and more fully developed by Gerald Dworkin (1972) and Joel Feinberg (1986). One of thebioethicists' strongest arguments against medical paternalism turned out to be the distinctly Millian,ruleutilitarian claim that when it comes to selfregarding choices bearing on medical treatments,paternalistic interventions by physicians will almost always do more harm than good, if not in theshort run then at least in the long run as a matter of standard medical practice and social policy. Suchfragmentary appropriation of elements drawn from high moral theory is ubiquitous in the field ofbioethics.

2.5 Convergence theories

A similarly eclectic approach to high moral theory stresses the convergence of differing theories at thelevel of action guiding principles. No matter what the differences between, say, utilitarianconsequentialism and Kantian deontology at the highest level, it is sometimes claimed that such rivaltheories will predictably reach the same results both at the level of midlevel principles and at theconcrete level of particular judgments. One wellknown example of this phenomenon is provided byBeauchamp, who described himself as a ruleutilitarian, and Childress, who described himself as apartisan of religious deontology, in early iterations of their highly influential joint project on theprinciples of biomedical ethics. Despite their differences at the level of foundational moral theory,both of these philosophers expected their ultimate differences to recede at the level of moralprinciples, where they could agree, for example, on the importance of the principle of autonomy andits overriding significance in the area of research ethics and the physicianpatient relationship, even iftheir ultimate justifications at the level of high moral theory would tend to diverge (2009, 36163).

2.6 Common morality theories

Two rival “common morality” theories, elaborated respectively by Beauchamp & Childress andBernard Gert, currently dominate the field of bioethics (Beauchamp and Childress 2009, Gert 2006,Arras 2009). Whereas pluralistic moral theories are defined in terms of the number and kind of basicmoral norms they defend, common morality theories focus on the ultimate source of our principles,rules, and ideals. Both of these approaches trace that source to a common morality supposedly sharedby all people of good will. Such theories are, however, also decidedly pluralist insofar as theyencompass moral rules, principles and ideals that address a host of disparate consequentialist anddeontological moral concerns bearing on killing, lying, beneficence, justice, etc.

Beginning with the third edition of the Principles of Biomedical Ethics, published in 1989,Beauchamp and Childress relocated the source of their midlevel bioethical principles from highphilosophical theory to what they have termed ‘‘the common morality.’’ By insisting on the definitearticle here, they meant to distinguish the wide variety of particular moralities found in different eras,cultures, and professions from their source in a morality that is common, as they put it, to all personsin all times and places who are committed to living a moral life. This morality encompasses both rulesof obligation (e.g., do not kill or cause suffering for others, tell the truth, keep promises, do not steal,prevent evil or harm from occurring, rescue persons in danger, do not punish the innocent, obey thelaw, treat all persons with equal moral consideration, etc.) and standards of moral character, such asnonmalevolence, honesty, integrity, truthfulness, fidelity, lovingness, and kindness.

[15]




Beauchamp and Childress assert that the content of the common morality is dictated by the primaryobjectives of morality, which include the amelioration of human misery, the avoidance of prematuredeath, and the predictable consequences of indifference, conflict, hostility, scarce resources, limitedinformation, and so on. Adhering to the norms of the common morality is necessary, Beauchampclaims, “to counteract the tendency for the quality of people's lives to worsen or for socialrelationships to disintegrate” (Beauchamp 2003, p. 261).

The moral authority of the common morality is thus established, according to Beauchamp andChildress, neither by means of ethical theory nor by means of a priori reasoning or reflection on themeaning of moral terms; rather, moral normativity is established historically or pragmatically throughthe success of these norms in all times and places in advancing the cause of human flourishing. Theiraccount is thus historicist, but unlike most historicisms it does not embrace moral relativism. Thenorms of the common morality, they insist, are universally binding.

Providing a mere thumbnail sketch of Bernard Gert's approach to common morality will prove to be amuch more daunting task because, in contrast to Beauchamp and Childress, Gert's primarycontribution to ethics and practical ethics just is his account of common morality. More specifically,Gert begins with a conception of the point and purpose of morality, which then yields the descriptivecore of common morality, including lists of the various moral rules and moral ideals, and a decisionprocedure for determining when it is justified to violate any of the moral rules. This descriptive core isthen shored up by Gert's theoryof common morality, which attempts to provide a justification for theentire edifice. Although Gert concedes that his particular theory of common morality might well beproblematic in various ways, although he doubts it, he insists that his account of the descriptivecontent of common morality is both true and universally embraced by all rational persons. For Gert,then, the point of ‘‘doing ethics’’ is not to come up with some nifty new theory of morality, but ratherto provide a faithful descriptive and interpretive rendering of the moral rules, ideals, and decisionprocedures that we all share. Borrowing a page from Wittgenstein, Gert declares that his accountchanges nothing in common morality, which does not change over time, leaving its central preceptsand decision procedures in place and intact (Gert 2004, p. 4).

Gert begins his account with the claim that the whole point and purpose of morality is to lessen theamount of evil or harm suffered in the world [2004, p. 26], a goal similar to that posited byBeauchamp and Childress. He then dips into a quasiHobbesian account of human nature, arguing thatbeings like us—i.e., vulnerable, mortal, rational, and fallible (p. 8)—would favor adopting commonmorality as a public system that impartially applied to everyone. The content of common moralityconsists of moral rules and moral ideals. Given the point of morality, all ten of the rules (aDecalogue!) proscribe actions that either directly cause harm, (e.g., killing, lying, causing pain,disabling, depriving of freedom or pleasure) or tend to produce harmful results (e.g., do not deceive,break promises, cheat, disobey the law, or fail to do your duty). Whereas the moral rules categoricallyprohibit violations (unless sufficient reasons can be provided), the moral ideals merely encouragepeople to prevent or relieve the sorts of harms covered by the rules.

In what sense are the common morality approaches of BeauchampChildress and Gert moral theories?While the former have not abandoned their belief that their principles of biomedical ethics could bederived from disparate but converging high level theories (2009, 36163), they now stress the origin



of their principles in ordinary, universally shared moral beliefs rather than in some special moralsensibility, pure reason, rationality, natural rights, or some grand normative ethical theory. EchoingRawls's comment on the pivotal role of socalled “considered moral judgments,” Beauchamp andChildress now consider any conflicts between common morality and moral theory to tell against thecredibility of the theory. Taking this common morality as a given of human history and experience,BeauchampChildress are prepared to defend its principles on pragmatic grounds and to deploy thosesame principles in concrete moral and policy analyses through a process of increasing specificationand balancing. Although they thus distance themselves from theory as a source of ultimatejustification for their working principles, they still refer to their position as a “common moralitytheory” in order to distinguish it from other fundamental approaches to bioethics.

As for Gert, he too regards the repository of common morality to be a given of sorts. All peoplecommitted to the spirit of morality will, he asserts, agree on the basic rules and ideals embedded incommon morality. And like Beauchamp and Childress, Gert does not found the tenets of commonmorality upon any of the usual moral theories, about which he tends to be fairly dismissive. On theother hand, Gert regards the elaboration, interpretation, and systematic defense of the commonmorality to be his own contribution to philosophical theory.

2.7 Normative theories of limited scope

Another more modest version of normative theory (compared to high theory) includes theories ofrelatively narrow scope and ambition, focused upon particular problems or recurring themes. Incontrast to common conceptions of high theory, which envision it as perched on a shelf, more or lessalready fully articulated and awaiting any and all applications to particular moral problems, somenormative theories grow out of particular struggles with particular moral problems and thus have amore limited scope than more paradigmatic normative theories, such as utilitarianism or deontology.In attempting to characterize his own very creative approach to the linked problems of abortion andeuthanasia, Ronald Dworkin (a frequent contributor to the bioethical literature, even if not abioethicist malgré lui) refers to his own approach alternatively as a theory developed from the insideof these moral problems, as a theory “made for the occasion” rather than prefabricated, a theory, inshort, tailored on Saville Row rather than mass produced on Seventh Avenue. Thus, instead ofinvoking various familiar moral theories bearing on liberty and autonomy, Dworkin develops a theoryof value focused upon clashing views of the “sacredness” of human life as manifested in debates overabortion and euthanasia (Dworkin 1993). As we saw in the main body of this entry (Sec. 6), a widevariety of midlevel theories of limited scope constitute perhaps the greatest theoretical contributionof philosophy to bioethics.

3. Metaethical theoryAlthough most theorizing in bioethics falls squarely under the heading of normative ethical theory—i.e., substantive accounts of what is good, virtuous, obligatory, etc.—theoretical issues of anotherkind, i.e., socalled “metaethical” concerns, often lurk in the background. These deeper, morefundamental questions have traditionally encompassed controversies surrounding the very point andpurpose of ethics, the meanings of ethical terms (e.g., “right” and “good”), what it means to hold anethical view (i.e., do ethical judgments merely express subjective preferences?), the objectivity of

[16]




moral judgments and the possibility of ethical truth, and how we might best justify our moraljudgments.

Although most working stiff practical ethicists manage to get through their careers without botheringtoo much about the debate between metaethical internalists and externalists—i.e., whether there is aninternal, necessary connection between one's moral beliefs about doing X and one's correspondingmotivations regarding the doing of X—some distinctly metaethical questions are harder to avoid, evenwithin a practical field like bioethics. For example, one very fundamental and much discussedquestion in bioethics has to do with the sources and limits of moral justification. According to oneinfluential view, our actions or policies are morally justified insofar as they are validated by somemoral principle or other, but rival metaethical views contend, for example, that moral justification isachieved, not by appealing to principles alone, but rather by appeal to various paradigm cases, as incasuistry, or to the harmonious totality of our intuitions, rules, principles, moral theories, andbackground social theories (i.e., reflective equilibrium). Thus, the entire debate among bioethicistsconcerning the respective merits and demerits of various methods of conducting bioethical inquiry—including principlism, narrative, casuistry, and reflective equilibrium—is itself an unavoidablemetaethical question. Indeed, the entire present essay is itself an extended metaethical exercise.

Another important metaethical issue concerns the very possibility of ethical truth, objectivity, orjustification within the sphere of secular bioethics. H. Tristram Engelhardt, Jr. has argued forcefully,if not entirely convincingly, that there is quite simply no canonical articulation or ordering of valuesin the secular, public square, and thus that there can be no foundational public bioethics based uponcontentfull conceptions of things like dignity, equality, or liberty (1996). Because we cannot agree onsuch fundamental matters in our socalled “postChristian,” “postmodern” age, contends Engelhardt,most of contemporary bioethics, and especially those views that aspire to articulate and justify our“common morality,” are essentially fraudulent. Worse yet, he claims, the state or medical professioncannot act upon the edicts of contemporary bioethics without violating the autonomy or dignity of allthose (usually flinty, contrarian, well off Texans) who happen to disagree with today's bienpensant bioethicists. Were it convincing, Engelhardt's metaethical theory thus would have importantnormative theoretical consequences—for example, we would all have to be libertarians “by default.”

4. Metaphysical theoriesFor all of its emphasis on downtoearth practice, bioethics harbors a number of explicitlymetaphysical controversies that ultimately play important roles in normative argument.Unsurprisingly, many of these controversies arise on the borderlands between life and death. Theproblem of abortion poses the question, “When, exactly, does a fullfledged human being or ‘person’with the full panoply of human rights come into being?” At the other end of life's journey, we ask,“When, exactly, does a person die?”, and in order to address this question, we need to proffer adefinition of death itself. Is death best defined in terms of the human organism or rather in terms ofthe person's ability to reason or her embodied brain? Although some might prefer to finesse suchdifficult questions by appealing straightaway to more tractable normative arguments bearing,respectively, on harms to women stemming from illegal abortions or the diminished value of life in apersistent vegetative state, a satisfactory account of such issues will require an explicitly metaphysicalexamination of the nature of being human and of personal identity (DeGrazia 2005, McMahan 2003).



Bioethics is thus fraught with important metaphysical debates that simply cannot be finessed byappeals to common sense or institutional practices. In addition to the wellworn metaphysical debatesover moral status and personhood, so prevalent in the literature on abortion and brain death, the themeof personal identity plays an important role across a number of fronts in bioethics, including debatesover advance directives and reproductive ethics. One particularly interesting and importantcontribution involves the deployment of Derek Parfit's socalled “nonidentity problem” in the contextof reproductive ethics (Parfit 1986). Critics of various reproductive technologies (such as cloning,surrogate parenting, and in vitro fertilization) often claim that such controversial techniques can resultin harms to the children conceived with their assistance and, thus, should either be banned or highlyregulated. Such harms might include various birth defects, the sequelae of premature birth, socialstigma, or the psychological damage associated with being a clone or an object of commercialtransaction between contracting parents and surrogates (President's Council 2002). As Parfit hasshown, such allegations often assume a standard account of harm according to which an actionadversely affects the welfare of a single, enduring, identifiable person—for example, a mother's heavydrinking might engender severe neurological deficits in her developing fetus, which would otherwisehave enjoyed normal health.

But what are we to make of reproductive choices that will determine the very identities of the childrenthey usher into existence? For such children (e.g., those born as a direct result of standard surrogacyarrangements or IVF) the choice isn't between a future threatened by possible psychological orphysical harms and another perfectly “normal” future without such harms; rather,assuming arguendo that there are psychological and somatic risks involved in these new reproductivetechnologies, the choice regarding the child is either for a life with a risk of some harm versus no lifeat all. A decision on the part of worried parents to opt for standard coital reproduction rather thansurrogacy or IVF would bring a different child, with a different identity, into being. Thus, if Parfit iscorrect, we cannot say that a child suffering from psychological or physical burdens resulting fromher high tech conception has been harmed by being brought into existence. We might still want to saythat the parents of such a child acted irresponsibly, assuming the controversial premise that the risksof harm were indeed high, but we cannot do so on the ground that the reproductive arrangementharmed the child, who owed her very existence to it. Although the alternative account we give of suchparental irresponsibility will no doubt depend upon a normative moral theory—e.g., the parents havebrought an excessive amount of needless suffering into the world (Brock 1995)—the need for analternative explanation is demonstrated by Parfit's expressly metaphysical argument.

To summarize the main results of this brief typology: (1) The field of bioethics is saturated withtheories of different sorts (normative, metaethical, and metaphysical) that exhibit different levels ofgenerality and comprehensiveness. (2) Invocations of theory in bioethics will be more or lessappropriate depending upon the particular level of bioethical practice in play—for example, whetherone is engaging in a clinical consult, advising a hospital committee or public ethics commission onpolicy, or teaching an undergraduate course or graduate seminar.

Documents

Theory and Bioethics _ a Taxonomy of Theoretical Work in Bioethics (Stanford Encyclopedia of Philosophy)